GW1--07519_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD For Internal Use ONLY!
This form can be used for single or multiple well.
1.Well Contractor Information:
GARRETT COLLIN BANKS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4519-A ft. ft-
NC Well Contractor Certification Number 1.5.OUTER CASING(for multi-cased wells)OR LINER(it'apt licable)
I RI OA 1 It) DIA NIP.TER I ItIC KS FSS S151 ERIAl,
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft- 80 tt• 6 1/4 i #21 PVC
Company Name 16.INNER CASING OR TERING geothermal closed-bop)
WEL2023-00034 FROM I,t III,s„ II t_-- 1HICRNESS SEAT ERI:,1.
2.Well Construction Permit#: _ f t II. +It.
List all applicable well permits(i.e.County,State,Variance.injection,etc.) ft. fr. III.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Publc ff ft. in.
❑Geothermal(Heating/Cooling Supply) E]Residential Water Supply(single) ft. ft. In.
❑Industrial/Commercial 0 Residential Water Supply(shared) IL GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 R• 20 it Bentonite Pumped
Non-Water Supply Well: ft. R.
❑Monitoring ❑Recovery Cap Top with Bentonite Chips
Injection Well: • ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM 10 SIAt ERI Al. F StP1.:ACEMENT SIFT HOD
❑Aquifer Storage and Recovery ❑Salinity Barrier n n
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM j TO I DESCRIPTION Icon...hardness.son,rock tspe,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 80 ft. OVER BURDEN
09/12/2023 80 ft. 605 It• GRANITE
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location:
ft. ft.
Haviture, LCC ft.
Facilits'Oss•ner Name Facility ID#(if applicable) ft ft. i l (� )��j
29 Haviture Way, Candler, 28715ft. ft. 0
Physical Address,City,and Zip 21.REMARKS
Buncombe 9606681927
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:(if well field,one lattlong is sufficient) I
N W C
6 C 09/29/2023
Signature of C'e.i, Well Contra tui Date
6.Is(are)the well(s): @Permanent or ❑Temporary By signing this jam,1 hereby certify that the we/l(s)was(were)constructed in accordance
with 15A NCAC 02C.0/00 or I5A NCAC•02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. C C SUBMITTALINSTUCTIONS
9.Total well depth below land surface: 605 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@l00') construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 30 (ft)
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 15 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013